F 0576
Ensure residents have reasonable access to and privacy in their use of communication methods.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to promote the residents' right to receive mail, for all
facility residents, in that:
Residents Affected - Many
Facility staff did not distribute mail received on Saturdays to the residents.
This deficient practice could result in residents not receiving mail in a timely manner and a diminished
quality of life.
The findings were:
During a confidential group meeting on 10/30/24 at 2:30 p.m., members of the resident group stated that
they do not receive mail on Saturdays and stated they feel this practice was disrespectful.
During an interview with the ADON on 10/31/2024 at 9:30 a.m., the ADON stated mail was not delivered to
resident's on Saturdays, unless they came up to the receptionist and asked for their mail.
During an interview with the ABOM on 10/31/2024 at 1:18 p.m., the ABOM stated he and the BOM did not
work on Saturdays, and that the mail received at the facility on Saturdays were left for them to sort and was
given to the residents on Mondays, unless the residents asked for their mail.
During an interview with the Weekend Receptionist on 10/31/2024 at 1:22 p.m., the Weekend Receptionist
stated she received the mail from the postman/woman on Saturdays and was instructed to leave all of it,
including the residents mail, for the ABOM and the BOM to sort and distribute on Mondays, unless a
specific resident came and requested their mail.
During an interview with the DON on 10/31/2024 at 1:34 p.m., the DON stated that residents should receive
their mail on Saturdays.
Record review of the facility policy, Resident Mail Delivery, undated, revealed Business office will receive
residents mail and will hand deliver it to resident's rooms day of delivery or next business day.
.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
676312
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676312
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - West S
222 Bertetti Dr
San Antonio, TX 78227
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation's, interview's, and record review, the facility failed to review and revise Resident Care Plans
after each assessment for 1 of 12 Residents (Resident #28) whose records were reviewed for care plan
revision/timing:
The facility failed to ensure Resident #28's care plan was revised the reflect use of locked box.
These deficient practices could affect any resident and contribute to Residents not receiving the care and
services they needed.
The findings included:
Record review of Resident #'s 28 face sheet , dated 10/29/24 , a 65 - year old male admitted to the facility
on [DATE] with diagnoses that included Heart Failure ( occurs when the heart muscle doesn't pump blood
as well as it should) , Type II Diabetes (condition that happens because of a problem in the way the body
regulates and uses sugar as a fuel and Unspecified Dementia ( a term used to describe a group of
symptoms affecting memory, thinking and social abilities),
Record review of Resident #28's quarterly MDS, dated [DATE], revealed a BIMS score of 15 which
indicated cognition was intact.
In an interview and Observation on 10/29/2024 at 10:35 a.m. Resident # 28 he stated that he is allowed to
keep his money in his personal safe as he pointed to a locked box on his bed side table.
In an interview on 10/29/2024 at 11:31 a.m. the MDS nurse she acknowledged she did not update Resident
#28's care plan reflecting his use of a personal lock box as she was unaware that he was given a personal
lock box. She added that the staff risked possibly not all being aware that Resident # 28 had a personal
lock box by her not adding it to the care plan.
In an interview on 10/29/2024 at 9:00 a.m. the DON said the MDS nurse should have updated Resident
#28's care plan after quarterly MDS dated [DATE] because resident # 28 was provided a locked box prior to
the quarterly MDS 9/4/24. She added the potential harm was staff might provide incorrect care to Resident
#28. She stated her ADON was responsible for overseeing care plans and she audited them at random.
Record review of the facility policy Care Planning, 5/2007 , revealed the interdisciplinary team shall develop
a comprehensive person - centered care plan for each resident that includes measurable objectives and
time frames.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676312
If continuation sheet
Page 2 of 2
